Professional Documents
Culture Documents
Lorraine O. Ramig
Leslie Mahler
University of Colorado at Boulder and
National Center for Voice and Speech
Angela Halpern
National Center for Voice and Speech
William J. Gavin
Colorado State University, Fort Collins
ver the past 15 years, the Lee Silverman Voice Treatment (LSVT) has been established as the most efficacious behavioral treatment for voice and speech
disorders in Parkinsons disease (PD; Pinto et al., 2004;
Ramig, Countryman, Thompson, & Horii, 1995; Ramig, Sapir,
Countryman, et al., 2001; Ramig, Sapir, Fox, & Countryman,
2001; Schulz, 2002; Yorkston, Spencer, & Duffy, 2003). To
American Journal of Speech-Language Pathology Vol. 16 95 107 May 2007 A American Speech-Language-Hearing Association
1058-0360/07/1602-0095
95
Method
Participants
Fifteen participants (10 men, 5 women) diagnosed with
idiopathic PD were recruited from the Denver, CO, area to
participate in LSVT-X treatment. All participants signed the
human consent form approved for this study by the institutional review board of the University of Colorado, Boulder,
and were provided therapy free of charge. Because the performance of these participants was intended to be compared
with results from a past study, all 15 recruited participants were
placed directly in the LSVT-X treatment group (henceforth
X-PD). However, in order to make sure their level of motivation was consistent with past participants, during recruitment
all individuals were told that they could be placed at random
into either a 1-month group (receiving treatment four times
a week for 4 weeks) or a 2-month group (receiving treatment
twice a week for 8 weeks). All participants expressed willingness to join either group. At the end of the study, all participants were debriefed regarding the pretense that there were
two treatment groups. One male participant was discharged
midway through the therapy due to complications from an
unrelated medical condition, and results from 2 female participants were later omitted after their diagnoses changed from
idiopathic PD to Parkinsons Plus syndromes (one participant was diagnosed with multiple systems atrophy and the
other with progressive supranuclear palsy).
The final group of 12 new participants (9 men and 3 women)
was compared before and after treatment with two other groups
of participants from an earlier study conducted by members
of the same research team (Ramig, Sapir, Fox, & Countryman,
Spielman et al.: LSVTExtended and Parkinsons Disease
97
Treatment
Participants in the X-PD group received two 1-hr sessions
of LSVT-type treatment per week for 8 consecutive weeks.
Treatment followed the tasks and hierarchy of traditional
LSVT (Ramig, Countryman, OBrien, Hoehn, & Thompson,
1996; Ramig et al., 1995), except the hierarchy was distributed
over 2 weeks for each type of task. In brief, LSVT uses multiple repetitions of high-effort, loud, sustained ahs (15 repetitions), high- and low-pitch glides (15 repetitions each of
high and low pitch), and functional sentence repetition (5 repetitions of 10 sentences) to train healthfully produced, increased
loudness. These daily tasks make up the first half of the
treatment sessions. This louder voice is then carried over into
speech using a hierarchy in which the utterances increase in
length and complexity over the 4-week period. The speech
hierarchy makes up the second half of the treatment session.
As in the typical LSVT schedule, participants also completed
5 to 10 min of homework once a day on treatment days, and
20 to 30 min of homework on nontreatment days. Homework
sheets with assigned tasks and carryover activities were provided at each session and completed by participants on a daily
basis. Other than extending the treatments sessions over a
longer period of time, the main difference between the two
approaches is that LSVT-X requires a significantly greater
amount of home practicing (96 assignments for LSVT-X
versus 40 assignments for LSVT). The Appendix provides a
comparison of the two treatment schedules. As noted above,
home practice was not optional, and the clinician began each
session with a check of all assigned homework and carryover activities.
Data Collection
Participants were recorded twice during the week before
therapy (pre1 and pre2), twice immediately after therapy
Perceptual Ratings
Four speech-language pathology graduate students took part
in a listening study designed to evaluate perceptible changes in
connected speech following treatment, using a paired comparison paradigm. Listeners were presented with a pair of
sentences extracted from a reading of The Rainbow Passage
(Fairbanks, 1960) for each participant, recorded during pre1
and post1 data collection sessions. Sentence pairs were extracted at random from six possible sentences, and normalized
for SPL using a custom-built MATLAB software program
(Mathworks, 1999). Although therapy focused on increasing
vocal loudness, we chose to examine other aspects of speech
that would indicate improvement in speech and voice production, because we already had objective measures of
SPL. Specifically, raters were asked to base their judgments
TABLE 1. Mean age, time since diagnosis, stage of disease (Hoehn & Yahr, 1967), voice and speech severity, and voice and speech
characteristics for participants in each of three groups.
Group
X-PD
Participant
1
2
3
5
6
7
8
9
11
13
14
62
45
60
61
82
80
75
70
71
69
69
15
62
67.2
10
M
SD
T-PD
M
SD
Years since
diagnosis
Voice and
speech severity
11
4
5
5
6
0.5
7
8.5
3
4
1
2
3
2
3
3
3
2.5
2
1
1
0
2
5
4
3
4
3
1
5
2
4.8
3.1
2
2.5
0.5
2
2.6
1.7
67
17
59
59
2.5
10
12
14
60
51
76
4
4
3
5
0
4
19
23
27
35
37
74
79
80
61
76
17
1.5
3
20
4
0
3
3
5
38
40
42
67
75
66
7
15
8
2
3
2
2
1
4
3.1
1.2
2.9
1.7
2.5
2
3
3
1
0
4
3
3
2
1
2
2
1
0
3
2
2.5
3
2
3
3
4
1
3
2.2
0.7
4
2
2.3
1.3
M
SD
NT-PD
Age (years)
67.9
9
9
13
16
18
74
70
64
64
20
21
24
25
91
77
47
80
26
28
30
32
36
72
79
70
80
78
39
43
48
74
71.2
11.8
8.6
6.3
2
7
19
6
2
6
0.5
7
12
6
8
17
1
8
7.4
5.4
Note. Hoehn & Yahr stages range from 1 to 5, with higher stages indicating greater severity. Severity ratings of speech and voice deficits are on a
scale of 0 to 5, with 0 = none, 1 = mild, 3 = moderate, and 5 = severe. Dashes indicate that data were not available. X-PD = Lee Silverman Voice
TreatmentExtended (LSVT-X) Parkinsons disease (PD) treatment group; T-PD = treated PD group from Ramig, Sapir, Fox, & Countryman
(2001); NT-PD = untreated PD group from Ramig, Sapir, Fox, & Countryman (2001).
99
Statistical Analysis
Performance of the X-PD group on each of the four speech
and voice tasks for this study (sustained phonation, reading
The Rainbow Passage, monologue, and picture description)
was evaluated using a 2 3 4 completely randomized block
ANOVA design that examined differences between data collected at each time period (i.e., between pre1 and pre2, between
post1 and post2, and between follow-up1 and follow-up2
recordings). There were no significant differences between the
recording days at each time before and after treatment and
at follow-up, though an overall trend toward increasing intensity from the follow-up1 to the follow-up2 recording was
observed. Therefore, to simplify the ANOVA design and
increase its power, the data for each participant at each time
period were averaged to produce mean pretreatment, posttreatment, and follow-up scores. These data were then reevaluated using a 3 4 completely randomized block ANOVA
design. The first factor was the three levels of the assessment
time (pretreatment, posttreatment, and follow-up). The second factor was the four levels of the assessment conditions
(phonation, Rainbow, picture, and conversation). Post hoc
comparisons using Tukey tests were applied to determine which
means significantly differed from each other.
The interpretation and generalization of the outcomes of the
above analyses are restricted because this study of LSVT-X
does not have a control group that received either no treatment
or an alternative treatment as in previously published studies
on LSVT. To address the issues of generalization, it would
be desirable to know whether the treatment effect observed
in the participants receiving LSVT-X compares favorably to
the control groups or groups receiving typical LSVT (Ramig,
Sapir, Fox, & Countryman, 2001). However, given that the
earlier published data were collected under different experimental protocols in a different laboratory (albeit similar to the
current study), direct comparisons of group performances by
incorporating data from both studies into a single ANOVA
procedure may violate assumptions concerning equality of
variance, because the studies may have different sources and
degrees of measurement error. An alternative approach is available if one assumes that a reasonable estimate of the mean
vocal SPL of two different populations can be made from
the previously published data. The newly obtained data under
the LSVT-X protocol would be represented as a sample mean
to be statistically compared with each of the estimates of the
population means (published data) using a variation of z test
of means; in this case, a one-sample t test where the population variance needed for the error term is estimated from the
sample variance (Sheskin, 1997). In keeping with standard
practice of controlling for Type I errors by multiple testing, the
alpha level of a given t test is adjusted by dividing the familywise error rate of .05 by the number of tests performed, in this
case 24. Thus, the adjusted alpha level is .0021 for the analyses that are reported in Tables 3 and 4 (see discussion below).
The ANOVA and the one-sample t tests test were performed
using SPSS Version 12, and the post hoc t tests were calculated by hand according to the formulas described in Kirk
(1995).
Results
Questions 1 and 2: Is There a Significant Change
in Vocal SPL After LSVT-X Treatment? Were Any
Observed Changes Maintained at 6 Months?
The 3 4 randomized block ANOVA revealed that in all
conditions, substantial increases in SPL were seen from preto posttreatment, with slight decreases from posttreatment
to follow-up (see Figure 1 and Table 2). ANOVAs revealed a
significant main effect for time of assessment, F(2, 20) = 89.61,
p < .001, with a large effect size (h2 = .90). Post hoc tests
revealed a significant increase from pre- to posttreatment
(t = 8.80, p < .001), a significant increase from pretreatment to
follow-up (t = 7.42, p < .001), and a nonsignificant decrease
between posttreatment and follow-up.
There was also a significant interaction effect for Time of
Assessment Test Condition, F(2, 20) = 15.15, p < .001, with
a moderate effect size (h2 = .60). Post hoc testing indicated that
all speaking conditions showed significant increases in SPL
from pre- to posttreatment and from pretreatment to follow-up,
with the exception of conversation at follow-up. There was no
significant decrease in SPL from posttreatment to follow-up
for any condition.
FIGURE 1. Measurement of SPL at 30 cm in the Lee Silverman Voice TreatmentExtended group for four different
speech tasks before, immediately after, and 6 months after therapy.
four conditions. For the picture condition, the difference between the population mean derived from the T-PD group and
the X-PD sample mean was found to be statistically significant,
the X-PD group mean being larger. At 6 months, no statistically significant differences between these groups were found
in any of the four conditions.
As expected, statistically significant differences between
the population mean derived from the NT-PD group (control)
in the 2001 publication and the X-PD sample were found in
all four conditions after treatment and at follow-up, the X-PD
group having significantly higher SPL.
TABLE 2. Changes in SPL following LSVT-X from pre- to posttreatment and follow-up for individual tasks.
Comparison
M (SD ) dB SPL at 30 cm
Obtained t value
Significance (two-tailed)
Phonation
Pre- vs. posttreatment
Pretreatment vs. follow-up
Posttreatment vs. follow-up
10.12
9.87
0.25
<.001
<.001
.805
Rainbow
Pre- vs. posttreatment
Pretreatment vs. follow-up
Posttreatment vs. follow-up
6.44
5.61
0.84
<.001
<.001
.411
Picture
Pre- vs. posttreatment
Pretreatment vs. follow-up
Posttreatment vs. follow-up
6.57
4.95
1.62
<.001
.001
.121
Conversation
Pre- vs. posttreatment
Pretreatment vs. follow-up
Posttreatment vs. follow-up
5.65
4.14
1.79
<.001
.005
.089
101
TABLE 3. Comparisons of LSVT-X SPL means before treatment with sample means from Ramig, Sapir, Fox,
and Countryman (2001) representing estimates of two populations: a PD group prior to receiving treatment
and a PD control group not receiving treatment.
Group comparison
M (SD) dB SPL at 30 cm
Obtained t value
Significance (two-tailed)
Pretreatment of T-PD
Phonation
Rainbow
Monologue
Picture
1.56
1.35
0.99
1.80
.147
.203
.344
.099
Pretreatment of NT-PD
Phonation
Rainbow
Monologue
Picture
1.45
1.05
0.50
0.18
.174
.316
.626
.864
Notes. For all t tests reported above, df = 10, with the obtained p values evaluated against the adjusted alpha level of .0021
in order to be considered statistically significant.
TABLE 4. Comparisons of X-PD means after treatment and at 6 months to sample means from Ramig, Sapir, Fox,
and Countryman (2001) representing estimates of two populations: a PD group after receiving treatment
and a PD control group not receiving treatment.
Comparison
M (SD) dB SPL at 30 cm
Obtained t value
Significance (two-tailed)
82.4
77.9
74.5
74.4
(3.9)
(3.3)
(2.6)
(2.5)
0.82
1.96
1.86
4.34
.429
.076
.089
.001*
79.8
76.1
72.7
73.4
(4.7)
(3.5)
(2.6)
(3.1)
2.07
2.54
1.44
2.39
.065
.030
.180
.038
70.5
71.9
69.4
70.7
(3.9)
(3.3)
(2.6)
(2.5)
11.42
8.42
8.99
9.86
<.001*
<.001*
<.001*
<.001*
70.6
71.9
69.5
70.7
(4.7)
(3.5)
(2.6)
(3.1)
8.60
6.60
5.88
5.49
<.001*
<.001*
<.001*
<.001*
*Statistically significant as the obtained p value is less than the adjusted alpha level of .0021; for all t tests reported above,
df = 10.
using Tukey t tests revealed that both treated PD groups differed significantly from the untreated control group: X-PD,
t(13.5) = 2.34, p = .035; T-PD, t(13.5) = 2.64, p = .02. Results
indicate that the speech of both treated groups was considered better following therapy, compared with the untreated
group.
Discussion
The goal of this study was to evaluate whether LSVT-X,
an extended version of LSVT, delivered over 2 months (rather
than 1 month) with more home practice, can produce measurable speech and voice changes comparable to those typically seen following traditional LSVT. Results for this group
of 12 participants indicate significant changes in vocal SPL
following LSVT-X. These changes appear consistent with
traditional LSVT when compared with population means from
an earlier study (Ramig, Sapir, Fox, & Countryman, 2001).
Participants receiving LSVT-X were also perceived as having
better speech after therapy compared with before, and were
not considered significantly different in this regard from
participants who had received traditional LSVT. Finally, selfratings using the VHI also suggest that on the whole, participants who received LSVT-X were less negatively affected by
their voices following treatment and did not perceive decline
over a 6-month period. Self-ratings of vocal improvement
reached statistical significance at posttreatment and follow-up
for at least 25% of participants. As the participants in the
historical LSVT study did not complete the VHI, these results
cannot be compared across studies.
The main differences between LSVT and LSVT-X are the
distribution of the 16 treatment sessions over 2 months (versus
1 month), the amount of directed home practice, and the length
of time between treatment sessions. Given that participants
in the X-PD group received as much direct treatment as traditional LSVT clients, it is not entirely surprising that outcomes
were similar. In fact, while the total face-to-face time with a
clinician was equivalent, the length of time to consolidate
new motor programs was twice as long and the amount of
homework practice was more than twice as much for the
LSVT-X group. This increased practice time may partially account for why participants in the X-PD group improved and
compared favorably to the T-PD group from 2001 (Schmidt &
Lee, 1999). The X-PD group had 8 weeks instead of 4 weeks
for learning the target voice, with 2 weeks at each level of
the hierarchy. In addition, the X-PD group practiced more than
twice as much on their own (96 homework assignments compared with 40). These assignments also included individualized carryover communication tasks, thus increasing the
opportunities for more specific practice and generalization
over a longer period of time. Although in this study the members of the X-PD group did not perform significantly better
than the historical LSVT group, the trend toward increasing
vocal SPL from follow-up1 to follow-up2 in the X-PD group
raises the question of whether target motor patterns might have
been better established in this group.
It was somewhat surprising that the relative frequency of
feedback did not appear to negatively affect the outcomes of
the LSVT-X participants. During traditional LSVT, the clinician provides feedback for 4 consecutive days over 4 weeks,
103
as a functional measure of change. Results indicated that immediately following treatment, vocal SPL increased for all
participants during reading and for all but 2 during sustained
phonation. Three months later, most of these gains were substantially reduced. While results suggest positive immediate
outcomes for different LSVT schedules, they cannot be easily
compared with published LSVT efficacy studies due to significant differences in methodology. For example, 4 of 11 participants chose their preferred group due to transportation
issues, resulting in incomplete randomization. This method
also produced unbalanced groups, with 3 in the 4 4 group,
2 in the 2 8 group, and 6 in the 2 4 group. There were also
significant differences in data collection. In contrast to other
LSVT studies, participants in this study were cued to phonate
loudly before and after treatment, and so spontaneous gains in
vocal SPL could not be accurately measured after treatment.
Furthermore, treatment was administered by graduate students
who were supervised by a certified LSVT clinician, but not
certified themselves. It is therefore difficult to draw conclusions about which variables affected the outcome.
Readers should bear in mind several limitations of the
current study as well. Although the use of historical data for
comparison is not uncommon, further study with concurrently
collected control data is recommended to avoid potential
measurement error and differences in medical care that may
have influenced the groups in unpredictable ways. Also, because the LSVT-X group was led to believe there were two
different treatment schedules available, while the LSVT group
was not, the two groups were not completely randomized and
may have had different expectations.
There is a clear need for more and varied ways to administer LSVT, or any efficacious treatment, so the greatest number of people can benefit from speech-language pathology
services. However, the need to increase accessibility of
treatment ought to be tempered by the greater need to maintain
efficacy of treatment protocols (Trail et al., 2005). Although
principles such as intensity of motor training have long been
accepted in terms of behavioral recovery and improved function,
only recently have the neurobiological phenomena underlying such principles been stringently validated for the positive
effects on central nervous system functioning (Cotman &
Berchtold, 2002; Kleim et al., 2003; Vaynman & Gomez-Pinilla,
2005). Thus, efforts are ongoing to develop creative technologies that provide greater access at lower cost without disrupting the intensity or frequency of treatment. Recent advances
include technologies that allow clients to receive treatment
from a clinician at a distance (e.g., telemedicine; Hill &
Theodoros, 2002; Mashima et al., 2003), as well as computer
devices that help administer treatment and collect data. Devices include the LSVT Companion (LSVT-C; Halpern et al.,
2004), a specially programmed personal digital assistant
(PDA) that is designed to help clients work independently and
collect data for speech-language pathologists to assess therapy
progress. Preliminary results from a study of this device indicate that participants of various ages and with little or no computer experience can use the LSVT-C successfully and, when
used for a portion of their 16 treatment sessions, make gains in
vocal SPL comparable to those reported in previous studies
(Ramig, Sapir, Fox, & Countryman, 2001). Also in development is the LSVT Virtual Therapist (Cole, Ramig, Yan,
Acknowledgments
This research was supported by Grant R01 DC00150 from the
National Institutes of Health. We are extremely grateful to Jill
Petska for her help with numerous aspects of this study, and to
Elizabeth Coger, Heather Gustafson, Samantha Magnuson, and
Marissa McRay for their help with the perceptual study. Finally,
special thanks to the participants and families who participated in
this study.
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Appendix
Traditional Lee Silverman Voice Treatment (LSVT) Versus Extended Version
(LSVT-X) Treatment and Homework Schedule
LSVT (four 1-hr sessions per week)
Note. Homework is done for 5-10 min once on treatment days and 10-15 min twice
(each time) on no-treatment days. Each homework assignment includes individual
carryover activities for that day, as well as individualized readings for the hierarchy level.
107